25 reasons to kill meaningful use

ver the last half decade, the Federal Government has successfully convinced a majority of physicians and hospitals to begin using electronic health records by providing $30+ billion dollars in subsidies to those who use an ONC Certified electronic health record (EHR) according to the “Meaningful Use” guidelines.

Although the physician community usually consists of a multiplicity of dogmatic opinions, on the subject of Meaningful Use (MU), there is now near unanimous agreement that the MU train has not succeeded in achieving its intended purpose, which was to improve quality or reduce the cost of healthcare. Earlier this month, 111 medical organizations, led by the AMA, sent a letter to Congress asking that MU Stage 3 be delayed and MU Stage 2 be redesigned.
Dissatisfaction with MU even extends to the Chief HIT Geek, John Halamka, M.D., who has concluded MU “Stage 2 and Stage 3 will not improve (health) outcomes” and has called to “Replace the meaningful use program with alternative payment models and merit-based incentive payments.”
In an attempt to objectively assess the MU program, I put together a list of reasons to help me determine whether the MU program should be continued or terminated:

Reasons to Continue the Meaningful Use Program (Pro MU)

• Some late adopting physicians and hospitals will continue to receive significant financial payments from the Federal Government if they participate in MU programs.
  
  
• Computerized Physician Order Entry (CPOE) and electronic prescribing have been demonstrated to reduce medical errors.

Reasons to Terminate the Meaningful Use Program (Con MU)

• The majority of physicians already use EHR and there is no reason to continue to incentivize them.
  
  
• There is a ground swell of discontent among physicians arising from the poor design of many Certified EHRs and the current MU program further enshrines the use of these EHRs.
• Many physicians believe that MU program interferes with the physician-patient relationship by forcing physicians to spend time acknowledging clinically meaningless Certified EHR prompts.
• Hospital resources devoted to meeting MU requirements have hindered some hospital’s ability to update their IT infrastructure by drawing resources away from important IT problems.
• MU mandates have onerously consumed EHR vendor and healthcare provider resources while decreasing resources which can be devoted to creating innovative healthcare solutions.
• Physicians do not believe (nor is there data to demonstrate) that forcing patients to visit the physician’s MU mandated patient portal promotes the health of their patients.
• Physician practices are overburdened with bureaucratic mandates (Rx appeals, insurance requests for records) and MU tasks consume staff and physician time, thus diverting them from patient care.
• There are substantial financial penalties and psychological costs which physicians will incur if they are audited as a result of their participation in the MU program and these financial penalties are disproportionate to the financial incentives arising from the MU program.
• Only 12% of physicians have completed MU stage 2 and fewer will likely participate in MU3.
• The collective burden of all the workflow changes required by three stages of Meaningful Use regulations will make it hard for clinicians to spend adequate time on direct patient care (John Halamka, M.D., http://geekdoctor.blogspot.com)
• The public health reporting requirements required by MU will be hard to achieve in many locations due to the heterogeneity of local public health capabilities (John Halamka, M.D.)
• There is no data which proves that achieving MU Stage 1 or Stage 2 improves the quality or reduces the cost of healthcare
• A majority (68%) of physicians report MU measures do not help them improve patient care or safety. (Survey of Texas Physicians Meaningful Use. Texas Medical Association)
• A decision to work towards a “delay” in MU Stage 3 program will enshrine the currently intrusive and wasteful MU1 and MU2 work protocols as part of the standard office visit.
• While there is great promise which may derive from true HIT interoperability, there are many ways to achieve HIT interoperability independently of the MU
• It is illogical to hold physicians responsible for implementing HIT mandates which are clearly beyond their ability to create, pay for and/or implement
• Meaningful use has ” created … a monster, when really what we were shooting for was good patient care.”  (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems and Health Policy. The RAND Corporation, American Medical Association 2013)
• Reducing the cumulative burden of rules and regulations may enhance physicians’ ability to focus on patient care. (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems and Health Policy)
• The current approach to automated quality reporting does not yet deliver on the promise of feasibility, validity and reliability of measures or the reduction in reporting burden placed on hospitals. (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Floyd Eisenberg,Caterina Lasome, Aneel Advani, Rute Martins, Patricia A. Craig, Sharon Sprenger. 2013)
• The workflow changes to meet the MU eCQM reporting tool requirements have added to physician and nursing workload, providing no perceived benefit to patient care. (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Eisenberg et al)
• EHRs are not designed to capture and enable re-use of information captured during the course of care for later eCQM reporting. (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Eisenberg et al)
• Champions of EHR adoption within hospitals …. have been significantly challenged by Meaningful Use Program eCQMs that are complex, inaccurate, outdated and that require incredible detail to be documented (often in duplicative ways) in a structured form in the EHR with no perceived additional value to patient care.  (A Study Of The Impact Of Meaningful Use Clinical Quality Measures. Eisenberg et al)
• Fifty two percent of Texas physicians report all or most of the (MU) measures are not meaningful to care. (Survey of Texas Physicians Meaningful Use. Texas Medical Association)
• There is essentially no data which demonstrate that the vast majority of meaningful use measures (excluding clinical decision support and computerized provider order entry) improve the quality of patient care.  (Ann Intern Med. 2014;160:48-54)
• The existing MU program has had a deleterious effect on physician morale. (Robert Wachter, The Digital Doctor: Hope, Hype Harm at the Dawn of Medicine’s Computer Age)

I fully acknowledge that the above lists are imperfect and that some will quibble over specific items on the lists. I want to encourage readers to add items to the “Pro” and “Con” lists in the comments section of this article, but please do so respectfully and in a measured manner. Inflammatory rhetoric will only denigrate the effectiveness of this conversation and serve no useful purpose.

Despite the imperfect nature of the above lists, I think we can objectively conclude that it is time for the Federal Government to immediately terminate the MU program.

I believe that the AMA’s strategy to delay/revise the MU program is the wrong goal. If they succeed in delaying the implementation of MU3, they will have enshrined MU1 and MU2 protocols into the practice of medicine and this will permanently interfere with our ability to provide care to our patients while making it very difficult to implement innovative healthcare solutions which have the potential to solve our healthcare cost/quality problem.

Until there is objective evidence that the MU program has a salutary effect on our health care system, not only should the MU program be terminated, but the Federal Government and private insurers should also be prohibited from creating financial incentives and disincentives arising from the MU program.